Clinical Dashboard in the Intensive Care Unit: Need-Assessment and Survey about Attitudes and Acceptance of Tele-ICU from the Viewpoint of Nurses and Clinicians in the Intensive Care Unit.

Background: One of the most worrying aspects of medical area in developing countries is the Intensive Care Unit (ICU). This study aimed to evaluate the acceptability of the clinical dashboard by the users, prior to final use and their attitude towards this technology, as well as to examine the specific needs that Tele-ICU technology can cover in the form of a clinical dashboard. Materials and Methods: This study was conducted at Shahid Bahonar Hospital of Kerman, Southeastern Iran, with three ICUs, the first, second, and third sections of which had 10, 12, and 24 beds, respectively. Taking survey and need assessment of care providers, qualitative and quantitative analyses were undertaken to identify key positive and negative themes. The data were analyzed by SPSS software version 18. Results: About 82% of care providers in the ICU participated in this survey. The number of participants based on the groups in the survey was 98 (81.7%) of the nurses and respiratory therapists group, 20 (80%) from the group of anesthesiologists and 20 (87%) from the group of anesthesiologist assistants who participated in the survey. About 51% of the survey participants completed the description section either partially or totally. On average, among all groups, the group of anesthesiologists had the most and the nurses had the least knowledge about telemedicine and Tele-ICU, whereas the anesthesiologist assistants had the most and the nurses and respiratory therapists group had the least knowledge about clinical dashboards. Conclusion: This study showed that the level of knowledge and awareness of care providers, especially nurses and respiratory therapists in the ICU in terms of telemedicine and Tele-ICU is low and care providers are in doubt that telemedicine technology could have a positive or negative impact on human resource shortages, yet agreed that it would have a negative effect on the privacy of the patients and care providers. In addition, the ICU care providers agree that Tele-ICU can positively affect the quality of patient care, staff satisfaction, reduce the cost of care, and ease and reduce the time for patient counseling. This suggests the need for further research and education of system impact beyond patient outcomes related to this new technology.

encounter the challenge of population aging and the increase of old population in the health care system (5). On the other hand, one of the main causes of ICU patient's hospitalization in Iran is road accidents (6). Considering the fact that the growth rate of road accidents in Iran is 20 times faster than that of the global average (7), and that Iran has the most road accidents in the world (8), it is necessary and inevitable to pay attention to the growth rate of hospitalized patients in ICUs in Iranian hospitals.
Nurses and clinicians who work in the ICU are required to have more experience and skills than other staff who work in the health care system, mainly due to their work type and its sensitivity. Studies have shown that staff experience in the ICU will have a direct impact on the quality of patient care (9). On the other hand, the health care system in Iran suffers from a shortage of manpower, especially a trained work force, and the ratio of manpower to patient in the ICU of Iranian hospitals is much lower than the global average (10). Therefore, staffs in the ICU are encountering shortage of time due to the compactness of the work, and one of the ways to overcome this problem is to delegate some time-consuming, important, and supervising tasks to technology. One of these technologies in the field of health is telemedicine, which in the ICU area, can be interpreted as Tele-ICU.
Patients in the ICU need constant and continuous care and, given that in this section, the patients' data is increasingly being generated from various software and hardware resources, accurate monitoring of these data is very important and vital (11). One of the initiatives that can improve this monitoring is the use of Tele-monitoring tools. The remote technology used in the present study to monitor the patient's condition in the ICU is a clinical dashboard. The clinical dashboard is an integrated system and provides its users with relevant and timely information to help them make the right decisions in improving patient care. Accessing to several different data sources, in fact the clinical dashboard provides information in a visual, summary, concise, and high-end format (12). In the present study, we integrated data from two different data sources, namely, vital signs monitors and hospital information system in the ICU, and therefore, using a clinical dashboard, these data were provided to nurses and clinicians in the ICU. In fact, we asked them to examine the clinical dashboard instead of reviewing the patient's paper in order to evaluate the effect of the clinical dashboard on the quality of patient care. Dowding et al. in their article review examined the role of clinical dashboards focused on improving patient care (13). Also, studies have been conducted to examine the role of Tele-ICU on patient costs and patient outcome (14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24). Some of these studies have mentioned some advantages for the use of Tele-ICU (15)(16)(17)(18)(20)(21)(22)(23)(24), yet some of the recent prospective studies have not had a significant impact on patients' outcome (14,19).
Many of the Tele-ICU technologies used in these studies have been developed by commercial vendors and one of the limitations of these products is the lack of attention to the role and benefits of the patient in terms of using. One of the limitations of such products is the lack of personalization and lack of attention to the specific needs of care providers in using them, so that important aspects such as patients' privacy, data confidentiality, reliability, and trust in the integrity of product results are neglected and/or not properly addressed (25). Another obstacle to the use of Tele-ICU technologies mentioned in the previous studies is the reluctance and resistance of care providers in using them (15,21). Generally, the user's consent and motivation in using technology is mentioned as one of the main factors of the success of IT projects (26

Research environment and study setting
This study was conducted at Shahid Bahonar Hospital of Kerman, the center of trauma in southeastern Iran. The center included three ICUs, the first, second, and third sections of which had 10, 12, and 24 beds, respectively. Also, the bed occupancy rates in these three sections were respectively 96, 94, and 92% at the end of September 2017.
Generally, patients admitted in these three sections were multi-service trauma patients with an average APACHE score of 19. The ratio of nurses to patients in any part of a day was 2:1. The total numbers of nurses employed in these three sections was 110 and the numbers of respiratory therapists and anesthesiologists were 10 and 25, respectively. Also, due to the educational nature of the center, 23 anesthesiologist students were involved in these three areas. The average work experience of nurses was 7 years and older (Table 1). providers and its problems were resolved.

Participants
In this study, 138 care providers from three groups were invited to participate in the survey. The characteristics of the participants are shown in Table 1. 1. Nurses and respiratory therapists who have had at least 6 years of work experience in ICUs (t= 98).
2. Anesthesiologists who have had at least 9 years of work experience in the ICU (t= 20).
3. Anesthesiologist assistants (students) who have had at least 2 years of work experience in the ICU (t= 20).
In the present paper, all care providers involved in the ICUs of the study area were included in the study and, therefore, the sampling method was census.

Preparation and data collection
Due to the fact that the concept of telemedicine and Completed forms were analyzed after being collected.

Data analysis
Based on the characteristics of the questionnaire, the analysis of the study was carried out in three parts: quantitative, semi-quantitative, and qualitative. In order to analyze the quantitative part, the percentage of the Also, common topics and areas of the comments were extracted and the responses were categorized accordingly.
To record the data and to perform the statistical analysis, Microsoft Excel 2010 and SPSS 18 software were utilized.     Table 3).   Table 4).

RESULTS
20% of the participants, all of whom were from assistants and only one physician was among them, had suggested that the system could provide a type of remote consultation among the physicians which help them to transfer the knowledge (Table 4).
Most participants with 54 and 64% agreed on the negative effects of Tele-ICU and clinical dashboard on the privacy of personnel and patients. In the comments section, participants were worried about the patient's data and information security due to the web-based system of the clinical dashboard. On the other hand, many opinions emphasized that the use of the camera to monitor the patient's situation threatens the privacy of personnel and patients (Table 4).   (Table 4).

DISCUSSION
Telemedicine in the ICU is presented as a potential to overcome the challenges ahead and providing a range of special services with a desirable quality to the patients and partly compensate for the lack of expert human resources (30). Although recent studies in the US claimed that the development of Tele-ICU can lead to improving the patient outcomes (15)(16)(17)(18)(20)(21)(22)(23)(24), yet recent studies have not shown the evidence of the benefits of this technology to the patient's outcomes (14,19 Two important issues in this study expressed concern about the Tele-ICU system: the first problem was laziness of care providers due to the use of clinical dashboard information, which results in taking away from the patient's bedside, which is not pleasant; the second concern was the privacy of the patients and care providers in using this technology, which must be addressed and resolved.
Another aspect to be addressed is the legal and security issues through which the patient data and their images are transmitted on the web and should be considered in order to enhance the security of this information and create a secure and appropriate context.
The purpose of this study was to provide a relatively unique evaluation of telemedicine and Tele-ICU before its implementation and deployment in one of the most critical medical areas. To prevent the opposition from the staff and to increase its acceptance by the care providers, patients, and relatives, necessary measures must be considered.
Although before implementing dashboard clinical in the ICU, the attitudes were measured, yet this does not mean that after its implementation, the system will work successfully, and will follow all goals set; the only thing that is important was the publication of these experiences and taking advantage of them in deploying the system as much as possible.
Due to the fact that the concept of telemedicine and